The inquest into baby Kaylan Coates death has revealed some shocking truths about the state of affairs at one of the largest maternity units in Nottingham.

Mother of Kaylan, Hayley Coates, attended the Queens Medical Centre on 20 March 2018 to be induced. Two days later, she was noted to be ‘struggling’ and yet her request for caesarean section was ignored.

The Coroner concluded that had this request been acted upon and escalated to doctors, Kaylan’s death probably would have been avoided.

The Coroner also found that both doctors and midwives did not treat changes in Kaylan’s heart rate with the seriousness it demanded. In fact, the heart rate readings (CTG trace) were miscategorised on a number of occasions.

Kaylan was born with a fractured skull, associated bleeding and brain damage due to the lack of oxygen, and died shortly after.

Flagged on a number of occasions by the CQC, concerns have been raised about the competency of staff at Nottingham’s maternity units to interpret CTG traces. As was the case for Kaylan Coates, the CQC found evidence that staff are not always interpreting, categorising or escalating CTG traces appropriately.

Online training on how to interpret CTG traces has been flagged as not fit for purpose, given that no competency assessments, other than an online test, have been required. Upon failing the online test, staff have not been followed-up.

We understand weekly CTG meetings were held at the Trust where outcomes for interesting cases were discussed. Staff members were expected to attend at least 12 per year. However, the CQC have found midwives rarely attended the meetings given the staffing issues on the ward. What’s more, the Trust could not provide evidence to the CQC that learning points were being relayed to staff, as no agendas or minutes of the meetings were kept.

We understand that the CQC have taken urgent enforcement action to mitigate the immediate risk to women and their babies. Jane Williams, Partner and Head of Clinical Negligence at Freeths in Nottingham, has commented: 

“The coroners findings in this very tragic case come only weeks after the damning report of the CQC was published. It is of grave concern to everyone in Nottinghamshire that lessons are only now finally being learnt by the Trust and urgent improvements are made to the maternity services to avoid any other families having to suffer the devastating loss of a baby”

We have recently seen an increase the number of women contact us with concerns over CTG interpretation during their labour.

If you or a loved one have similar concerns, please do not hesitate to contact us for a free, confidential discussion.

Please phone/email Jane Williams on: 0845 272 5724 or email 

Alternatively, please contact:

Gemma Bedford: 0115 935 0367 /

Jessica Atkin: 0115 985 3367 /

Adrian Denton: 0115 985 3335 /

Phillip McGough:  0845 050 3290 /